Healthcare Provider Details

I. General information

NPI: 1558536623
Provider Name (Legal Business Name): M. BEARDSLEE ANESTHESIA SVC. PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 DUBOIS DR MARILENE BEARDSLEE C/O KOSCIUSKO COMMUNITY HOSPITAL
WARSAW IN
46580-3210
US

IV. Provider business mailing address

PO BOX 1296
WARSAW IN
46581-1296
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-3200
  • Fax:
Mailing address:
  • Phone: 574-268-9640
  • Fax: 574-268-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28065229A
License Number StateIN

VIII. Authorized Official

Name: MARILENE O BEARDSLEE
Title or Position: OWNER/PRESIDENT
Credential: C.R.N.A.
Phone: 574-267-6167